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Anthony Infantolino, MD, AGAF, FACG, FACP
Professor
Director, Barrett’s Esophagus Treatment Center
Co-Director, GI Bleeding Center
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania

 

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Christina Tofani, MD
Assistant Professor
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania

 

Barrett’s esophagus (BE), intestinal metaplasia with goblet cells, affects 0.5% to 2.0% of the general population.1,2 BE, especially with dysplasia, is a precursor lesion for esophageal adenocarcinoma (EAC). The incidence of EAC has risen rapidly and, despite therapeutic advancements, the prognosis remains poor.1,3 Recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines recommend ablation of dysplastic BE using radiofrequency ablation (RFA) or cryoablation, and endoscopic mucosal resection (EMR) of visible BE lesions.4 Guidelines from the American College of Gastroenterology also identify risk factors for BE, including chronic gastroesophageal reflux disease (GERD), male sex, age over 50 years, white race, central obesity, tobacco use, and a family history of either BE or EAC.2

Case Presentation

A 63-year-old white man was referred to gastroenterology for GERD. The patient reported at least 10 years of reflux symptoms, described as burning in his chest and epigastric region, occurring 3 to 4 times per week. He was using omeprazole 20 mg as needed, which provided some relief. He denied dysphagia, odynophagia, and family history of esophageal cancer. He reported active tobacco use (40 pack-years). On physical examination, he was a well-appearing, obese man (body mass index, 36.1 kg/m2). An esophagogastroduodenoscopy (EGD) was performed.

EGD, using high-definition white light endoscopy (HD-WLE), narrow band imaging (NBI), and near-focus imaging, revealed salmon-colored mucosa extending from the gastroesophageal junction (GEJ) to 1 cm above the top of the gastric folds (38–39 cm from incisors) in a circumferential manner. There was an 8-mm nodule located at the GEJ in the 1 o’clock position. Careful examination of the nodule, using HD-WLE, NBI, and near-focus imaging, revealed an abnormal vascular pattern. An EMR of the nodule was performed using Duette® Multi-Band Mucosectomy (Cook Medical). The remainder of the salmon-colored mucosa segment was sampled using cold forceps biopsies.

The nodule pathology showed well-differentiated, intramucosal adenocarcinoma (T1a) arising in the background of BE with both low-grade dysplasia (LGD) and high-grade dysplasia (HGD). There was no evidence of lymphovascular invasion, and lateral and deep specimen margins were negative for EAC. The lateral margins were positive for BE with dysplasia. The pathology from the remainder of the biopsied segment revealed BE with HGD. The patient had a PET/CT negative for distant metastatic disease. The patient also opted to have surgical and oncology consultations, both of which deemed endoscopic management with EMR and ablative therapy to be the best treatment option (Figure).

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Figure. Initial endoscopy showing salmon-colored mucosa at the GEJ (A). Low magnification of atypical cystic glands within muscularis mucosae consistent with T1a adenocarcinoma (B). GEJ and distal esophagus after RFA was performed (C). HD-WLE shows no evidence of residual BE (D).


BE,
Barrett’s esophagus; GEJ, gastroesophageal junction; HD-WLE, high-definition white light endoscopy; RFA, radiofrequency ablation

Images courtesy of Anthony Infantolino, MD, AGAF, FACG, FACP, and Christina Tofani, MD.


Eight weeks later, repeat EGD was performed showing 1 cm of BE (Prague criteria C1M1) with a well-healed EMR site and no apparent nodules or areas of concerning vascularity. RFA of the segment was performed using the Barrx™ 60 RFA Focal Catheter (Medtronic). The patient was placed on a modified, soft diet for the following 5 days and prescribed omeprazole 40 mg BID, as well as sucralfate and oral lidocaine to be mixed with an over-the-counter (OTC) liquid antacid for pain control.

Twelve weeks later, the patient returned for repeat EGD. On careful examination, there was a single tongue of BE mucosa extending approximately 1 cm above the GEJ. No nodules or areas of abnormal vascularity were noted. RFA of the BE mucosa as well as the GEJ was performed using the Barrx 60 RFA Focal Catheter. The patient again was placed on a modified, soft diet for the following 5 days, as well as sucralfate and oral lidocaine to be mixed with an OTC liquid antacid for pain control. He was told to continue omeprazole 40 mg BID.

Twelve weeks after, the patient presented for repeat EGD. Examination using HD-WLE, NBI, and near-focus imaging revealed a normal-appearing squamocolumnar GEJ, squamous-appearing epithelium in the esophageal body, and no other areas concerning for BE. No RFA was performed. Four-quadrant cold forceps biopsies of the gastric cardia, GEJ, and distal esophagus (1 cm above the GEJ) were performed. All biopsies showed no evidence of intestinal metaplasia. EGD was repeated every 3 months for a year and then every 6 months for the following year. All biopsies have shown no recurrence of BE or EAC. He is currently undergoing yearly EGD and remains on omeprazole 40 mg daily.

Discussion

The incidence of EAC is rising in the Western world, and BE is the known precursor lesion to this deadly cancer.1,3 Identification of patients at risk for BE or EAC and screening appropriately with EGD is vital. ACG guidelines recommend screening men who have chronic GERD and 2 or more risk factors for BE or EAC. If salmon-colored mucosa concerning for BE is found, at least 8 random biopsies should be obtained. If confirmed on EGD, the BE segment should be reported using the Prague criteria.2,5

Management of BE includes adequate control of GERD symptoms with proton pump inhibitors and either endoscopic surveillance or ablative therapy depending on the presence or absence of dysplasia. All EGDs should be performed with high-definition endoscopes using HD-WLE, NBI, and near-focus imaging to perform a very detailed examination of the entire BE segment. Any nodules or mucosal abnormalities with concerning vascular patterns should be removed by EMR, as they may harbor cancer.2

BE patients with either LGD or HGD should be considered for ablative therapy. In BE patients with LGD who cannot/chose not to undergo ablative therapy, EGD with 4-quadrant biopsies every 1 cm (Seattle protocol) should be performed every 6 to 12 months. The most widely accepted ablative treatment is RFA.2 In a sham-controlled trial, 85.7% of patients undergoing RFA achieved complete eradication of dysplasia (CED) and 77.4% achieved complete eradication of intestinal metaplasia (CEIM).6 In a large meta-analysis, the pooled percentage of patients achieving CED was 91% (95% CI, 87%-95%) and CEIM was 78% (95% CI, 70%-86%). The recurrence rate of BE after CEIM was 13% (95% CI, 9%-18%).7

Management of BE and early EAC demands both patient and provider commitment with close, meticulous endoscopic surveillance of nondysplastic BE, treatment of dysplastic BE with ablative therapy, and recognition and successful endoscopic resection of early EAC, with the ultimate goal of preventing progression to invasive EAC.

References

  1. Runge TM, Abrams JA, Shaheen NJ. Gastroenterol Clin North Am. 2015;44(2): 203-231.
  2. Buttar NS, Wang KK, Sebo TJ, et al. Gastroenterology. 2001;120(7):1630-1639.
  3. Wani S, Qumseya B, Sultan S, et al. Gastrointest Endosc. 2018;87(4):907-931.e9.
  4. Sharma P, Dent J, Armstrong D, et al. Gastroenterology. 2006;131(5):1392-1399.
  5. Shaheen NJ, Sharma P, Overholt BF, et al. N Engl J Med. 2009;360(22):2277-2288.
  6. Orman ES, Li N, Shaheen NJ. Clin Gastroenterol Hepatol. 2013;11(10):1245-1255.